Three weeks ago, I mentioned in a post that the week of October 7 to 14 was declared by our very own United States Senate to be Naturopathic Medicine Week, which I declared unilaterally through my power as managing editor of Science-Based Medicine (for what that’s worth) to be Quackery Week. One wonders where the Senate found the time to consider and vote for S.Res.221, which reads:

S.Res.221 – A resolution designating the week of October 7 through October 13, 2013, as “Naturopathic Medicine Week” to recognize the value of naturopathic medicine in providing safe, effective, and affordable health care.

I know, I know, it probably took all of five minutes to consider and vote for this, thanks to Sen. Barbara Mikulski (D-MD), who sponsored it. In any case, as October 7 approached, I thought about how I could keep my promise to blog about naturopathy this week, and I came up with a way to do it. So, first I wrote about naturopaths and vaccines. It’s a bit roundabout, but I think it fits. The idea derives from a discussion I was having a while back about one of my “favorite” hospitals, namely the Cancer Treatment Centers of America, in which a colleague of mine questioned why there were so many CTCA ads on NPR and why CTCA is sponsoring shows on PBS such as the upcoming The Emperor of All Maladies by Ken Burns. Although I can’t wait to see this particular series, I am a bit worried that the infiltration of quackademic medicine will make an appearance, given that CTCA is a major sponsor.

With this as my entry point, I noted that CTCA is very much into “naturopathic oncology” and that it’s been over three years since I’ve written about this. Given that this is Naturopathic Medicine Week 2013, this seemed like an excellent way to begin, with a recap and update on the nonsensical therapies that CTCA provides. In many ways, CTCA is the very epitome of “integrative medicine,” and I don’t mean that in a good way. (Actually, there is no good way to be the epitome of “integrative medicine,” which “integrates” pseudoscience and quackery with real medicine.) Then, late last year, it was revealed that Richard Stephenson, the founder of CTCA, is also one of the primary funding sources for Freedom Works, a right-wing Tea Party organization that was a major player in the 2012 elections. It was an interesting little tidbit in that it is yet another reminder that the tendency towards medical woo is not limited to the stereotypical crunchy granola-eating left wing fringe. Be that as it may, let’s take a look at what CTCA is offering these days. When I did this, I found a lot of the same ol’ same ol’, but one new development that echoes another frequent topic of this blog.

But what does CTCA offer in terms of “integrative” treatments these days? I wandered over to the section on integrative oncology services, and this is what I found. Naturally, I couldn’t resist heading first to the section on naturopathic medicine, particularly given that this is naturopathic medicine week. This is what CTCA touts, after declaring that naturopathic clinicians are “specialists in natural health care who use natural, non-toxic therapies to support the whole person and encourage the self-healing process”:

Throughout your treatment, your naturopathic clinician will recommend natural therapies to support your immune system and reduce any treatment-related side effects, including:

Herbal and botanical preparations, including herbal extracts and teas.

It’s rather amazing here how so many of the things that are wrong with “integrative oncology” are right there on a single page. Look at the list of therapies. They range from the purest quackery (homeopathy) to what should be science-based medicine (physical therapy and exercise therapy) and everything in between. I realize that most readers of SBM know what homeopathy is and why it is quackery, but in case there are new readers seeing this, I’ll briefly recap. Homeopathy postulates two main ideas, both of which have no basis in science: First that you relieve symptoms by using a substance that causes the symptom being treated, and, second, that diluting a substance makes it stronger. Of course, the substance must be diluted with strong shaking (known as “succussion” in homeopathy lingo) between each serial dilution step. Most homeopathic remedies are diluted so much that there is almost certainly nothing left of the original remedy. For example, Avogadro’s number (the number of molecules in a mole of a substance) is on the order of 6 x 1023. A typical homeopathic dilution is represented as “C,” where each “C” equals a 1:100 dilution. So, a 1C dilution is a 1:100 dilution; a 2C dilution is a 1:10,000 dilution (100 x 100); and so on. If you get to 12C, you’re talking a 1024 dilution, which is already greater than Avogadro’s number. That means that it’s unlikely that more than one molecule of the substance remains, and that assumes the homeopath started with a mole of the substance being diluted, which is rarely the case. Usually the homeopath starts with much less. Now consider that typical homeopathic dilutions are 30C (1060), more than 1036 orders of magnitude greater than Avogadro’s number, and just how quacky homeopathy is comes into focus. Sure, homeopaths will wave their hands about the “memory or water” or “nanoparticles,” but in reality homeopathy is nothing more than magical thinking. The same is largely true for acupuncture, which is nothing more than a theatrical placebo, and studies claiming otherwise are uniformly unconvincing.

Now let’s look at some of the other “integrative” treatments. They are a classic “rebranding” of science-based modalities as somehow being “alternative.” For example, physical therapy and exercise therapy have been well-accepted treatments for various musculoskeletal problems for a long time. There is nothing “alternative” or “integrative” about them. There is one caveat. Frequently, the “alternative” or “integrative” versions of these sorts of therapies get that way by “integrating” magical thinking into them. I can’t tell how much magical thinking has found its way into CTCA’s version of physical therapy and exercise therapy, but given who’s in charge of rehabilitation at CTCA (Karen Gilbert, certified in auriculotherapy and lymphatic drainage), I’m guessing that it’s probably a lot, particularly given the easy access to chiropractic and these recommendations for rehab:

Our chiropractors treat bone, muscle or joint pain, without the use of drugs or surgery. Chiropractic care can also help to relieve symptoms such as neuropathy, nausea and headaches.

Auriculotherapy

This painless, non-invasive form of oncology rehabilitation, which involves stimulation of the auricle of the external ear, can help alleviate some of the side effects of cancer treatments, such as pain, nausea or fatigue.

Then there’s lifestyle counseling, which is a vague one. That can range in science-based practices, from practical advice on how to lose weight to exercising more and getting more sleep, but note how CTCA mentions nutritional supplements. It’s become increasingly apparent over the last several years that nutritional supplements are not necessary except in very specific (and relatively uncommon) cases of specific nutritional deficiencies, as long as the person eats a varied diet. Moreover, most studies of nutritional supplements for specific health conditions, with the possible exception of vitamin D, have been resoundingly negative.

One thing becomes clear as you peruse the treatment options offered at CTCA for virtually any cancer, and that’s that naturopathic treatments are deeply embedded (or “integrated”) into everything that is done at CTCA. Indeed, if you click on almost any cancer in this list, you’ll see three buttons. For instance, under the section on breast cancer, there are three buttons:

Some naturopathic remedies, such as green tea and melatonin, may help to decrease the risk of breast cancer recurrence.

Some endocrine treatments that are recommended for women with breast cancer are given for at least five years and have side effects that naturopathic medicine can help address. This allows you to tolerate these treatments and continue with important therapies to help decrease risk of recurrence.

Then there is this video that recommends supplements to combat cancer- and treatment-related fatigue. Vitamin D, of course, is not anything unique to naturopathy; when indicated it should be a part of standard treatment, not something recommended by a naturopath as an adjunct. Second, acupuncture and homeopathic remedies do nothing for nausea, and the evidence suggesting that green tea might decrease the risk of breast cancer recurrence is weak at best. So is the evidence that naturopathic treatments can significantly alleviate the symptoms of estrogen deprivation due to anti-estrogen drugs used to treat hormone-positive breast cancer.

There’s so much more, of course, but I’m trying to train myself not to be as verbose as perhaps you’ve become accustomed to (anything over 5,000 words is too much). The bottom line is that CTCA is indeed the epitome of “integrative” oncology in the way it truly does seamlessly “integrate” woo with science-based medicine such that it’s difficult for patients to distinguish what is science-based and what is not. Indeed, even physicians sometimes have difficulty telling where the SBM ends and the woo begins, even as otherwise excellent physicians and surgeons actually working at CTCA fall for the common trope that somehow taking care of the “whole patient” and being “holistic” means embracing pseudoscience, even touting it as what “sets CTCA apart.”

Disturbing echoes of another major topic of this blog

I’m going to leave the topic of naturopathic oncology for the moment, because, if there’s anything about CTCA that’s new, it’s not the naturopathy. Rather, it’s a new service CTCA offers that sounds a lot like a service I’ve been writing about for the last year and a half offered by our old “friend” Stanislaw Burzynski, specifically, his “personalized gene-targeted cancer therapy.” It’s basically using genomic testing to try to pick combinations of targeted therapies and chemotherapy that are likely to be most effective on any individual patient’s cancer. Go back and read that post. Now take a gander at CTCA’s webpage on Genomic Tumor Assessment, which boldly states:

Every cancer is different. Genomic testing helps our doctors understand a patient’s cancer at the molecular level. Information about genomic changes that are unique to your individual cancer will help us determine treatments most likely to work for you. It’s the promise of precision cancer treatment — a focus on the individual tumor in the individual patient.

Take a look at the video on that page. It’s very slick. It uses lots of 3D graphics showing DNA double helices and cells dividing. It sounds very convincing. However, much of it is, when you come right down to it, repackaging of things that conventional doctors already do. For instance, there’s a long section about colorectal cancer and how we know the proteins that drive the growth of colon cancer and, depending upon whether key genes are mutated, know which chemotherapies to choose. Ditto for breast cancer, where if the HER2 oncogene is turned up to 11, so to speak, we have a drug that targets it. In reality, this part of the video looks as though it’s just referring to these oncogenes that we already test for in colon cancer, non-small cell lung cancer, and breast cancer. There are already commercially-available tests for mutations in these genes, for example this one from Quest Diagnostics. None of this is particularly new, at least not anymore. CTCA even admits as much for non-small cell lung cancer and breast cancer, albeit in the small print, where it says that these tests have been done for several years as “part of the standard care.”

Here’s where CTCA claims to go beyond this:

If you and your oncologist decide you are a candidate for genomic testing, the following steps are taken:

CTCA collects a sample of your cancer tissue (if available) or a biopsy of your tumor and sends it to a respected genomic sequencing lab.

Sophisticated laboratory methods will capture genomic information in the tumor cells. Scientists at the sequencing lab extract the DNA from your tissue or tumor sample.

Genetic information is encoded as a sequence of nucleotides – guanine, adenine, thymine, and cytosine – which form the building blocks of DNA. Scientists at the lab then sequence the genes in your tissue or tumor sample to uncover the order of nucleotides.

Sequencing the tumor’s genetic profile produces a large amount of data. Scientists at the lab analyze this data to identify mutations that are critical to certain functions of the tumor.

Your oncologist will review the test results to determine if the information is helpful in the selection of a good treatment option for you.

All of this sounds to me a lot like what the Burzynski Clinic does. The question then becomes: Is CTCA any better at it than Burzynski is, the latter of whom, through the arrogance of ignorance, either thinks he “pioneered” this field twenty years ago (and that cancer centers like M.D. Anderson are only now following in the footsteps of his brilliance) or lies about his expertise in genomic testing and gene-targeted cancer therapy? The information is way too sketchy on the website to tell for sure, but it’s instructive to compare how CTCA sells “precision” medicine to how M.D. Anderson portrays it in the description of its Institute for Personalized Cancer Therapy:

Our strategic plan for the Institute is focused on the goal of defining the new standard of patient care – making personalized cancer therapy standard over the next 5 years, revolutionizing the way we manage patients. To accomplish this goal, we will:

Develop best practices for obtaining and managing patient biopsies and specimens to implement personalized cancer therapy;

Position MD Anderson to lead the way in therapeutic clinical trials based on the underlying genomic and molecular alterations in individual patient’s cancers;

Establish broad internal and external collaborations and partnerships to enhance our ability to rapidly transform discoveries into clinical practice and standard of care.

Note the emphasis on research and implementation. M.D. Anderson understands that “precision medicine” is not yet ready for prime time and that we don’t know yet whether or by how much the use of this genomic data for each patient’s tumor will impact patient care and outcomes. That’s why it has a research institute to develop the infrastructure and methodology for carrying out clinical trials to test “personalized” or “precision” medicine. Indeed, there has been some criticism of a “genomic gold rush,” in which cancer centers are seemingly competing to be the “firstest with the mostest” when it comes to genomic medicine. Even optimists point out that medicine is a long way from deriving useful information from routine tumor sequencing, much less improving patient outcomes.

I suppose that, in light of how the big cancer centers are going all-in, it’s not surprising that a for-profit hospital chain would want to emulate them. After all, don’t think that cancer centers aren’t using their new genomic institutes as marketing tools. However, there is a difference. The big cancer centers are building their genomic institutes in order to do the research necessary that will ultimately validate (or fail to validate) specific hypotheses regarding the use of routine genomic testing of patient tumor samples. There is enough uncertainty that, given the huge expenses involved and the massive effort this sort of research project takes, some are questioning the wisdom of setting these institutes up when the finances of medicine are so constrained right now and cost-containment is the order of the day. Even so, the goal, clearly, is to do the clinical trials that desperately need to be done.

In contrast, CTCA is selling genomic testing and personalized therapy as though it were already validated, as though it’s as routine and simple as sending off a piece of the patient’s tumor, either from a biopsy or a surgical resection, to the genomics lab to have it work its magic on the specimen, be it cDNA microarray analysis or the more recent advanced techniques like next generation sequencing, and then reading off the results. The implication is that we already know how to use the terrabytes of data that result from a typical sequencing of a single tumor to pick the best chemotherapy and targeted drugs for their individual cancer. Sure, there are disclaimers, but the overall message, complete with this spiffy infographic, is that this is cutting edge and that it will help cancer patients who come to CTCA. While there might be much to criticize when it comes to the “genomic gold rush,” the intent is to find out whether these techniques and the information they yield can greatly improve cancer outcomes. Now look at CTCA’s section on clinical trials. I don’t see any testing its Genomic Tumor Assessment to see if it provides information resulting in improved outcomes. Why is this? Indeed, look at this article on CTCA’s social media campaign for its “Real people. Real Discoveries.” campaign:

By launching the “Real People. Real Discoveries.” Social Media Campaign, CTCA places emphasis on key aspects of its core care delivery of genomic tumor assessment by emphasizing the importance of the individual’s genetic response and the potential it has for determining the best course of medicine and treatment. This focus inherently drives thoughts of “hope” without a specific reference to the word itself.

Notice that there isn’t any mention that this is still considered experimental. Rather, it is a media campaign designed to “drive thoughts of ‘hope'” without actually using the word itself.

Naturopathy and CTCA: Joined at the hip forever?

I’d like to finish by coming back to the topic of naturopathy, which might seem strange after discussing the use of genomic testing as a marketing tool. This is, after all, naturopathic medicine week, which is why I chose this topic in the first place. However, it is very clear that naturopathy is so completely embedded in CTCA that it taints the entire enterprise irredeemably. As I mentioned before, the impetus for founder of CTCA Richard J. Stephenson, was the death of his mother, Mary Brown Stephenson, from cancer and his frustration with the current system. Tragically, as so many before have done, in his grief and frustration, Stephenson confused “holistic” care with an openness to quackery like naturopathy and incorporated such quackery into CTCA right from the beginning, “integrating” it with standard, even state-of-the-art, conventional cancer care to the point where you can’t always tell where the science ends and the quackery begins. (Well, except for the homeopathy.) Sadly, a lot of otherwise-talented doctors bought into the idea and have—if you’ll excuse the term—completely “integrated” themselves into the CTCA system. In doing so, they have become complicit in the blurring of the line between science and pseudoscience in medicine while believing that they are doing good for the patient by giving them “holistic care.” While thinking they’re helping patients, they have become part of the problem.

I teach nurses and had a student who was a nurse at CTCA. She said their first concern was money and demanded proof on admission of ability to pay for all the quackery (and TV ads) over and above what insurance would pay. It was in the 10s of thousands of dollars. The TV ads imply, but never say, that they have cancer treatments that are superior to any other center. That deception keeps the patients coming. It was also clear that the nurses and physicians they hire are not the best in the business. Profit is their first priority and everything is done to extract as much as possible from patients. From a nursing perspective, it was clear to me that they were not trying to hire experienced certified oncology nurses, but rather nurses who were willing to work for low pay in a sketchy setting.

“Then, late last year, it was revealed that Richard Stephenson, the founder of CTCA, is also one of the primary funding sources for Freedom Works, a right-wing Tea Party…It was an interesting little tidbit in that it is yet another reminder that the tendency towards medical woo is not limited to the stereotypical crunchy granola-eating left wing fringe”

I’m not sure how you can draw this conclusion regarding Mr. Stephenson. Perhaps he’s just pandering to what he thinks the market wants and providing it to them at high cost?

I work with “Next Gen Sequencing” data all the time… the key issue here is read depth. That is, how many times we “read” each base in the DNA in order to pick up the full diversity of DNA sequences.

A genome scan like I think they’re suggesting wouldn’t have the sequencing depth to pick up a rare genetic event that would be useful. They’d have no trouble picking up, as Orac suggests, a heritable mutation or one that has spread very widely… but if the goal is to detect those few rare events that represent the malignant cancer… then next generation sequencing has to trade breadth of the sequencing for depth of sequencing… and that ain’t cheap.

Short version: Something about their description and infographic doesn’t seem right. Either they’re screening for only inherited risk factors, or they’re not sequencing deep enough to be worth it.

Donna was diagnosed with stage IV NSCLC told she had six months to live. We went to a local academic medical center where she received evidence based care that extended that six months to nearly three years. During that time and well after her passing I have seen on TV and in print advertising for CTCA. Their media buy is huge if you consider they are buying prime time news in NYC for the Philly center. Their print buy includes the NY Times Sunday edition.

Watching and reading CTCA message left me feeling at times perhaps this would have benefited Donna to a greater degree. Thank you for this, now I can put my second guessing away for good.

Donna was diagnosed with stage IV NSCLC told she had six months to live. We went to a local academic medical center where she received evidence based care that extended that six months to nearly three years. During that time and well after her passing I have seen on TV and in print advertising for CTCA. Their media buy is huge if you consider they are buying prime time news in NYC for the Philly center. Their print buy includes the NY Times Sunday edition.

Watching and reading CTCA message left me feeling at times perhaps this would have benefited Donna to a greater degree. Thank you for this, now I can put my second guessing away for good.

I am seeing several different topics being addressed here, but under one heading. I have to agree that, yes, some of these treatment options are indeed “quackery”; I will say however that there are plenty of benefits to chiropractic treatment, nutritional treatment, and exercise treatment–some benefits not entirely scientifically understood. But when you look at the way our brain works, besides what we have uncovered already, aren’t there many things we don’t understand? How stress causes more than just increased blood pressure or thinking positive can actually have positive effects on your health in the long run or how sleep therapy can be a remedy for a plethora of problems people are faced with.
It just seems a bit closed-minded to think of EVERYTHING as quackery–when constant advances are being made in somewhat parellel fields of medicine (or “naturopathics”), but those discoveries are often kept from being divulged because of lack of strong enough scientific data.
I am NOT condoning the advancement of non-scientific forms of medicine or anything like that–and believe me, the dilutions that are MANY orders of magnitude below any effective amount are BOGUS (that’s my equivalent to “quackery”)–but I am condoning the exploration of other forms of treatment and prevention of chronic illnesses. i.e. the many forms of cancer.
Fantastic article here! Forwarding a few friends and colleagues here to check this out!

If auriculotherapy was effective–if sticking needles in different points in the ear actually caused physiologic effetcs–wouldn’t we have expected to see a large increase in ER admissions corresponding to the increasing popularity of multiple ear-piercings? I’ve seen women (and men) with greater than a dozen earings, posts. etc. in place, none of which I must presume were emplaced with any consideration of what meridians they might effect.

I agree that the muddy presentation of both scientific and non-scientific treatment methods is extraordinarily misleading. What else can we do besides increase awareness of scientific treatment side effects and coping methods for each (if available/known)? Excellent article!

JustNuts @8: I don’t know. There seem to be an awful lot of ancient Eastern medical techniques that were developed in the early 20th century. For instance, reiki (which at least actually was developed in Japan, but dates from the 1910s).

I’m glad you addressed the fact that other cancer centers–scratch that, medical establishments in general–are marketing new technology for increased revenue from cancer patients; because of the cost of medical technology and the vast amount of research necessary to support or reject a hypothesis, they must draw in “customers”–we’ll call them patients, for their sake–in order to pay for the equipment, time, and other resources associated with cnacer treatment and discovery of new, optimized methods of treatment. Great information here, definitely biased, but great information nonetheless! Thanks, Orac.

“So, a 1C dilution is a 1:100 dilution; a 2C dilution is a 1:10,000 dilution (100 x 100); and so on. If you get to 12C, you’re talking a [10^24] dilution, which is already greater than Avogadro’s number.”

If anyone ever gets bored of this take-down of homeopathy, although it’s of course totally correct, I offer an alternative. Although it is an analogy only, so only different but not as good as the above.

1C dilution is equivalent to (astronomically) 5 visual magnitudes. A 7C “solution” of sunlight (-27 mag.) is much fainter (8 mag.) than what is visible to the unaided eye (6 mag.).

Going further, a 12C solution of sunlight (33 mag.) would be invisible in the Hubble Extreme Deep Field (31 mag. sensitivity), formed by staring at the same spot in the sky for over 3 weeks. In fact it is likely that not a single photon of diluted sunlight would be detected.

As Orac removes comments he thinks are advertising spam, the numbers readjust themselves. Thus, if you look back to see what someone called “spam” you’re now looking at something unobjectionable — or, at least, not spammy.

Does anyone else hope that Orac goes back to his normal verbose self? I felt a jolt of fear when I read this: “There’s so much more, of course, but I’m trying to train myself not to be as verbose as perhaps you’ve become accustomed to (anything over 5,000 words is too much).” The whole reason I come to this blog is for the depth of analysis, and amusing asides, that Orac provides.

Look a little more carefully. The “location” on each one of those comments contains a URL for the same domain, arcpointlabs.com.

It’s possible that three separate employees working for one company all decided in the course of a single day to make comments on the same blog entry, yes. But that each one should choose to list that company in their location, when most corporate policies *discourage* their employees doing anything which might be mistaken as them speaking on behalf of the company?? I think it’s spam: they’re not commenting because they really have anything to contribute, but just to promote whatever that site is.

ACK! In breast cancer patient support forums I see tons of references to “naturopathic oncologists” and it makes me cringe every time. Especially when it’s mentioned that they often work with patients remotely via phone and/or email consultations! Just arrange payment first and they’ll gladly hook you up with a scammy mail-order DIY blood testing lab and sell you some supplements and compounded hormones.

Yeah, I’m sick to the core right now of cancer quackery and it’s not even halfway through Puketober.

@newme
I wonder if its the same people who post over on the ovarian cancer forums. There aren’t all that many of the naturo. “oncologists.” At least, not that many “board certified” ones. What a joke.
One of them managed to recruit at least 40 patients, possibly 60-70, from one of the forums. (through two of her shills, of course. Naturo’s excel in avoiding accountability)

@mho – I’d say there’s a good chance. Do they post there pretending to be patients, raving about how great their ND is and inviting everyone to private message them for info? Yes, their recruitment efforts and apparent success (!) are mind-boggling, aren’t they? How do they sleep at night??

I wonder… I know there are “cancer registries” maintained at every major cancer treating medical center which tie in to national and even international mega-databases. There should be ways to analyze that mountain of data to find out if “naturopathic oncology” has any effect on outcomes.

Hi thenewme
I’ve missed you at our other site.
At the breast cancer support site i visit less and less frequently, the most critical you can get about CTCA without being attacked by flying monkeys is to tell people to make sure they take your insurance and to find out what that insurance will and will not cover.

Hi MIRose,
Thanks so much for noticing. I don’t have the heart to go there much anymore. Too many people treating breast cancer as a game, d’ya know what I mean? Anyway, you’re right about what can and can’t say without being banned/deleted. Ugh! Miss you too!

thenewme
You could come back to the Facebook group.
People on a breast cancer support group site who come there to sell their woo and come out with guns ablazin’ at the first hint of criticism set my teeth on edge, but to a lesser degree so does my friend who swears by acupuncture and keeps trying to send me to her acupuncturist. My tolerance for crap has gotten smaller every year.

The focus today with cancer is to eliminate it at all costs simply because that’s the only way our medicine method can profit from the illness. Whereas the focus should be addressing the underlying trigger or causes which will strengthen the immune system and the immune system will remove the cancer, but no one can profit from that. The purpose is, that’s only achievable by natural means.